Omar Abdalla

1. RBF CoP
Workshop
White Sands Hotel
Dar es Salaam
24th November 2015

2. Zanzibar Model: Key Goals of PBF
Primary Goals
1. Improve Quality of Services
2. Increase Utilization of Services
Secondary Goals
1. More Efficient Resource Usage
• Rational Prescription of Drugs
• Demand-driven inputs purchase
2. Improve Staff Retention
3. Strengthen community
involvement in improving
service delivery
 Facilitate the achievement of SDGs/improved Health
Outcomes

3. Zanzibar Model: Processes
Allocation
- by facility staff
- by MoH
Quarterly Performance Pay
Health Facility Performance
Facility
Staff
Bonuses
Community
Facility
Account
Performance
Pay
Measuring
Performance
Legend:
Facility &
Community
Verification
PBF Indicators
& Quality
Assessment
NB. Not all aspects of reform have been implemented yet.
30 Primary Health
Care Facilities
On Unguja and
Pemba (2 Districts)
Population xxx,xxx

4. Zanzibar Model: Why a quality focus?
Baseline facility performance
• Already relatively high OPD utilization: Average 1
visit per capita per year (adults and children
combined) overall and 2.1 under 5, 2012 (Global target
is 1 visit per capita per year and 2.3 visits per child <5 per year)
But….
• Low service quality: Average of <25% patients treated
according to guidelines (at baseline in pilot districts).
Infection Prevention Measures were no in place.

5. Quality Components
IPC checklistDirect quality indicators
attached to fee for service
Community Verifcation The 'Quality Tools'.

6. Curative indicators
Quantitative Qualitative Criteria
OPD- >5 years (new cases) – No payment According to Standard Treatment Guidelines
OPD- <5 years (new cases) – No payment According to IMCI
OPD (STI, Hypertension, Diabetes, Epilepsy) According to Guidelines
Minor Surgery Adjusted for Infection prevention and control
measures in place
Patients with three cardinal TB symptoms
referred/tested for AFB
Facility Delivery Partogram completed as per guidelines and
Adjusted for Infection prevention and control
measures in place

7. Components: Preventative indicators
Quantitative Qualitative Criteria
Children immunized against Penta 3 According to EPI guidelines
Children 6 monthly de-worming treatment
Vitamin A
Antenatal Visit (no payment) Four visits spaced with 4-6 week intervals according to FANC
Antenatal Visit (no payment) First Visit within 16 weeks
Postnatal care Within 48 hours according to guidelines
New Family Planning Consultation
Family Planning-Implant Adjusted for Infection prevention and control measures in place
Voluntary counselling & test for HIV ( PITC,
DCT )
PMTCT: HIV+ mothers and children treated
acc protocol
Tetanus vaccination of girls 12yrs and above
in schools

8. Results: Outpatients treated according to
guidelines (first year of implementation)

9. Results: IMCI guidelines adhered to

10. Impact on Health Outcomes/Child Mortality
• If treating children under 5 using IMCI guidelines reduces morbidity
and mortality then PBF will improve health outcomes for 60%
children in the PBF districts
• If zinc treatment for children under 5 following an episode of
diarrhoea reduces mortality and morbidity then PBF will improve
health outcomes in about 20% of the children in the PBF Districts

11. Unneeded antibiotic use in under 5s
207
330 260
441
526
553 784
48
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Non PBF 2013 Non PBF 2014 Pre PBF 2013 PBF 2014
<5 <5 <5 <5
with antibiotics Unneccessary antibiotics without antibiotics
Saving of
TZ16.5m
per year (2
districts/
(antibiotic
s only)

12. Rational antibiotic use – potential impact on
Zanzibar
• Cost of antibiotics prescribed but not required (estimated saving of
TZS 22million per year in the two PBF Districts)
• Increased number of antibiotics shared, uncontrolled, in the
community
• Antibiotic resistance
• Increased resistance in individuals
• Increased antibiotic resistance to low cost, first line antibiotics in the
population

13. Number of clients/patients served in intervention and Control PHCUs and its change
between two period
Intervention PHCUs Control PHCUs
Indicator April-
June
2013
April-
June
2014
Change April-
June
2013
April-
June
2014
Change DID
Number of children
immunized (Penta
3)
1147 1306 159 1112 1160 48 111
Number of
pregnant women
attended ANC first
visit within 16
week
621 907 286 516 472 -44 330
Number of
institutional
delivery
394 519 125 387 398 11 114
Number of OPD
cases
39280 38118 -1162 39657 41870 2213 -3375
Number of OPD
cases adhered with
guidelines
9784 31802 22018 15281 13884 -1397 23415

14. Possible reasons for reduction in OPD
attendance
Patients sought for treatment in
facilities where antibiotics were freely
prescribed, even for minor ailments.
Reduced health seeking in people
in need of treatment.
Reduced health seeking in people in need
of treatment.
Reduction of patients with minor
ailments

15. Improved adherence to
guidelines leads to improved
health outcomes
The Zanzibar PBF model improves
health worker adherence to
treatment guidelines and reduces
prescription of unnecessary drugs
(antibiotics)
However…stagnation of
curative out patients in PBF
Districts compared with
others requires further
investigation

16. Thank you for
your attention